Societies publish new guidance for the treatment of slow, irregular heartbeats

WASHINGTON (Nov. 6, 2018) -- The American College of Cardiology, the American Heart Association and the Heart Rhythm Society today released a guideline for the evaluation and treatment of patients with bradycardia, or a slow heartbeat, and cardiac conduction disorders.

In the guideline, bradycardia is defined as a heart rate of less than 50 beats per minute, compared to a normal heart rate of 50-100 beats per minute. A slow heartbeat can limit the amount of blood and oxygen that is pumped to all the organs of the body. Bradycardia is generally classified into three categories--sinus node dysfunction, atrioventricular (AV) block, and conduction disorders. In sinus node dysfunction, the sinoatrial node, the main pacemaker of the heart, cannot maintain an adequate heart rate. In AV block, there is partial or complete interruption of electrical impulse transmission from the atria to the ventricles. Cardiac conduction disorders occur when electrical impulses in the heart that cause it to beat are delayed. Common conduction disorders include right and left bundle branch block. Bradycardia and conduction abnormalities are more often seen in elderly patients.

The writing committee members outline the clinical presentation and approach to clinical evaluation of patients who may have bradycardia or conduction diseases. They reviewed study data and developed recommendations from the evidence. These recommendations include the selection and timing of diagnostic testing tools--including monitoring devices and electrophysiological testing--as well as available treatment options such as lifestyle interventions, pharmacotherapy and external and implanted devices, particularly pacing devices. The authors also address special considerations for different populations based on age, comorbidities or other relevant factors.

Conduction abnormalities are common after transcatheter aortic valve replacement (TAVR). The guideline includes recommendations on post-procedure surveillance and pacemaker implantation. The guideline also addresses ways to approach the discontinuation of pacemaker therapy and end of life considerations.

The writing committee members stress the importance of shared decision-making between the patient and clinicians, as well as patient-centered care.

"Treatment decisions are based not only on the best available evidence but also on the patient's goals of care and preferences," said Fred M. Kusumoto, MD, cardiologist at Mayo Clinic Florida in Jacksonville and chair of the writing committee. "Patients should be referred to trusted material to aid in their understanding and awareness of the consequences and risks of any proposed action."

Yet, according to the authors, there are still knowledge gaps in understanding how to manage bradycardia, especially the evolving role of and developing technology for pacing.

"Identifying patient populations who will benefit the most from emerging pacing technologies, such as His bundle pacing and transcatheter leadless pacing systems, will require further investigation as these modalities are incorporated into clinical practice," Kusumoto said. "Regardless of technology, for the foreseeable future, pacing therapy requires implantation of a medical device, and future studies are warranted to focus on the long-term implications associated with lifelong therapy."

The 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay will publish online today in the Journal of the American College of Cardiology, Circulation, Journal of the American Heart Association and HeartRhythm.

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The American College of Cardiology envisions a world where innovation and knowledge optimize cardiovascular care and outcomes. As the professional home for the entire cardiovascular care team, the mission of the College and its more than 52,000 members is to transform cardiovascular care and to improve heart health. The ACC bestows credentials upon cardiovascular professionals who meet stringent qualifications and leads in the formation of health policy, standards and guidelines. The College also provides professional medical education, disseminates cardiovascular research through its world-renowned JACC Journals, operates national registries to measure and improve care, and offers cardiovascular accreditation to hospitals and institutions. For more, visit acc.org.

The American Heart Association is a leading force for a world of longer, healthier lives. With nearly a century of lifesaving work, the Dallas-based association is dedicated to ensuring equitable health for all. We are a trustworthy source empowering people to improve their heart health, brain health and well-being. We collaborate with numerous organizations and millions of volunteers to fund innovative research, advocate for stronger public health policies, and share lifesaving resources and information. Connect with us on heart.org, Facebook, Twitter or by calling 1-800-AHA-USA1.

The Heart Rhythm Society is the international leader in science, education, and advocacy for cardiac arrhythmia professionals and patients, and the primary information resource on heart rhythm disorders. Its mission is to improve the care of patients by promoting research, education, and optimal health care policies and standards. Incorporated in 1979 and based in Washington, DC, it has a membership of more than 6,000 heart rhythm professionals in more than 72 countries around the world. For more information, visit http://www.HRSonline.org.